Abstract

Since the enactment of the Affordable Care Act (ACA) in 2010, conservatives have sought to undermine the law's entrenchment. While they have failed in their ambitious quest to repeal the ACA, opponents have succeeded in overturning one major provision (the individual mandate penalty), narrowing the law's reach, complicating its implementation, and fomenting doubts about its political sustainability. This essay places the postenactment battle over the ACA in historical-institutional perspective by juxtaposing the strategic choices that conservatives have made to limit the role of the federal government in the core social welfare areas of pensions and health since the New Deal. Our central argument is that conservatives' varying strategies of postenactment opposition, resistance, and accommodation for Social Security, Medicare, Medicaid, and the ACA have been shaped by shifts in conservative ideology, changes in control of institutional resources, and the nature of policy feedback. Attention to these contextual factors helps explain why ACA opponents viewed the law as a threat despite its moderate policy design, why opposition did not subside after the law's enactment, and how conservatives managed to keep the conflict going across multiple election cycles.

The political struggle over legislation does not necessarily end when a president signs a bill into law (Patashnik 2008; Maltzman and Shipan 2008; Berry, Burden, and Howell 2010). The battle over a law's fate—whether it will be repealed, narrowed, or expanded—may continue for years or even decades after enactment. Many factors shape whether a new program becomes a permanent, accepted feature of the policy landscape, including the level of support it enjoyed at adoption, subsequent electoral trends, court rulings, constituency mobilization, and whether a new law “once set in the ground seems to work” (Mayhew 2002: 119). Recognizing the contingency of policy entrenchment, opponents may try to prevent a reviled policy from sticking, while supporters may attempt to accelerate the embedding process (Patashnik and Zelizer 2013).

The sustained battle over the Affordable Care Act (ACA) illustrates just how contentious postenactment politics can be. Conservatives have used a variety of political, legal, and administrative tools to undercut the ACA's entrenchment. In many ways, the ferocity and persistence of conservative opposition to the ACA is puzzling. After all, the ACA was modeled on the 2006 Massachusetts health care reform law, signed by Republican governor Mitt Romney, that drew broad bipartisan support. It contained multiple ideas once advocated by conservatives, such as insurance purchasing pools and a mandate to require individuals to purchase coverage so they don't “free-ride” on others. The ACA also sought to fill in the cracks of the preexisting, employer-based insurance system rather than establish a new national health insurance program.

However, despite its moderate policy design, the ACA failed to win a single Republican vote in Congress in 2010. Further, GOP opposition to the law has remained steadfast even though the ACA has succeeded in achieving its central goal, substantially reducing the uninsured population, and critics' dire forecasts that the law would undermine economic growth proved inaccurate (Schoen 2016). To be sure, the ACA's implementation has been rocky, in part due to resistance from conservative officeholders. And it has done less to address the affordability of health care for the already insured than many Americans hoped (Kliff and Klein 2017). Nonetheless, the ACA has produced substantial benefits, including historic gains in insurance coverage and popular protections for people with preexisting conditions, that are not easy for officeholders to withdraw.

In the past, conservatives have often contested the enactment of new social welfare programs like Medicare but supported, or at least resigned themselves to, the policies once they won adoption. Why have conservatives remained unremittingly hostile to the ACA? Why have they fought the law at every juncture? To address these questions, this essay places conservatives' postenactment opposition to the ACA in historical-institutional perspective. We juxtapose the strategic choices that conservatives have made to limit and recast the role of the federal government in the core social welfare areas of pensions and health since 1935. Our discussion focuses selectively on major developments that span different programs and political eras. We trace conservative opposition following the enactment of Social Security (1935), Medicare and Medicaid (1965), and the ACA (2010).

Our central argument is that conservatives' varying strategies of postenactment opposition, resistance, and accommodation have been shaped by three key contextual factors: the evolving identity and ideological character of conservatism over time, changes in control of institutional resources, and the opportunities and constraints created by policy feedback. Attention to these factors helps explain why contemporary conservatives view the ACA as a grave threat despite its relatively moderate design, why conservative opposition did not subside after enactment, and how conservatives have managed to keep the conflict going across four federal election cycles.

Who Are American Conservatives?

In this essay, we define conservatives to include actors both inside and outside of government who generally favor “limiting governmental interference in social and economic relationships, loosening bureaucratic standards and restraints, and protecting the autonomy and diversity of civil society” (Skowronek 2009: 351). Conservatism is not a monolithic phenomenon but, rather, a dynamic force shaped by social movements, electoral trends, and the ideas of public intellectuals. As Glenn and Teles (2009) argue, the ideological character of conservatism has undergone dramatic change over the past century. Conservatism evolved from antistatist opposition to government growth and intervention in markets that prevailed in the 1930s to modern varieties that, by the 1970s, accepted liberal goals of promoting economic security while seeking to transform government through market mechanisms and conservative management.

Within Congress, the level, character, and partisan configuration of conservative opposition to social programs have changed markedly since the New Deal as a result of shifts in the policy agenda and secular trends such as the partisan realignment of the South. It has been difficult for scholars to capture these developments through quantitative analyses of roll call votes using standard measures like DW-NOMINATE (dynamic weighted nominal three-step estimation), which collapse “ideology” to one or two dimensions (across all issue areas) and ignore the changing historical and institutional context in which governance takes place. However, political scientists David A. Bateman and John Lapinski (2016) have recently developed a set of statistical techniques to address these concerns by generating issue-specific scores for each legislator across time.

Consider legislative voting patterns on Social Security. Figure 1 displays the median “ideal points” for Republicans, Democrats, Southern Democrats and Northern Democrats on Social Security–related measures between 1935 and 2007. The Republican Party has always been more conservative than the Democratic Party on Social Security. However, the GOP moved leftward on Social Security during the 1940s through the 1960s—the period when Social Security was expanding and gaining popularity and Medicare was created—before gradually moving back to the right in the 1970s, while the median Democrat moved leftward. Also notable is the changing position of Southern Democrats on Social Security. Between the 1950s and early 1960s, Southern Democrats voted more like the median Republican than like (liberal) Northern Democrats. Following the enactment of civil rights legislation, however, conservative southern legislators began to fade from the Democratic Party. By 1995, most members of Congress from southern states were Republicans, a trend that accelerated in subsequent years; in 2015, Democrats held only 24 of 155 House and Senate seats from the South (Henderson 2015). The few Southern Democrats who remained voted more like Northern Democrats. While the conservative opposition to liberal positions on Social Security included both Republicans and Southern Democrats in the 1950s, by 2007 conservative opposition was confined to the Republican Party.

The US Welfare State as Battleground

While the American welfare state is larger than commonly believed, it is nonetheless exceptional for its reliance on indirect forms of assistance, such as tax breaks, and its failure to reduce inequality and poverty (Howard 2007; Hacker 2002). The United States has traditionally emphasized programs that disproportionately benefit the upper and middle classes rather than the poor. These features are best understood as the outcome of political conflicts and accommodations among different actors and groups, mediated by institutional arrangements (Hacker 2002; Weir and Orloff 1988).

In her important book Policymaking for Social Security, Martha Derthick (1979: 370–71) drew a sharp distinction between conflicts over “boundary” and “distributive” issues: “Boundary issues, which entail enlarging the scope of the public sector, produce much more conflict than distributive issues, which entail the allocation of the costs and benefits of public activity.” Derthick's argument is broadly persuasive for the 1935–80 period and helps explain why conservative opposition to Social Security faded by the early 1950s and why political contestation over Medicare dissipated soon after the program's enactment.

However, in the current era of high polarization, a near parity of electoral competition between the parties, and rising income inequality, the dichotomy between the politics of boundary issues and the politics of distributive issues does not hold. It fails to capture the complexity of key issues, such as public regulation of private insurance markets. Most important, it misses two key features of American political development. First, boundary issues can be reopened long after many believed they were settled. For example, conservative intellectuals and then officeholders began calling for Social Security's privatization in the 1980s. Second, as the ongoing ACA debate shows, boundary and distributive issues can be contested at the same time, resulting in conflict over how to divide the public from the private sphere and over the degree to which government should mitigate inequality.

Strategies of Postenactment Opposition and Resistance

The aspirational goal of conservative welfare state opponents is to reverse the process by which services or goods are provided as a matter of right so that people can maintain living standards without exclusive reliance on the market (Esping-Anderson 1990: 21; Pierson 2001: 422). Conservatives who wish to tangibly advance their goals and not merely take symbolic positions confront two hard realities: first, social rights are difficult to claw back once granted, especially if the beneficiary group is organized and perceived to be morally deserving; and second, proposals that require new legislation must overcome the often substantial barriers to enactment. The strategic choices that conservatives pursue to remake the welfare state are thus shaped by the ideology and political priorities of conservative leaders, the political resources available to affiliated officeholders (including control over public authority), and the openings and constraints created by the feedback from inherited policy commitments.

As work by Hacker (2004) and others has stressed, conservatives can seek to undermine social policies in myriad ways during the postenactment phase, some of them visible and salient, others hidden and obscure. Table 1 provides a selective list of seven opposition strategies. The most direct way that conservatives can undermine a social policy after enactment is to try to repeal the policy. If repeal is infeasible, conservatives alternatively could undercut a preexisting program through more indirect, less visible, strategies. For example, they can pursue changes in indexation formulas to keep benefits from rising or create procedural hurdles that discourage eligible recipients from signing up for benefits. Conservatives also can aim to slow the growth of programs by imposing controls on costs. Or they can try to limit benefit levels and the coverage of new recipients.1

Conservatives can also attempt to undermine the legitimacy and reputation of welfare state programs through rhetorical attacks alleging such programs are financially unsustainable or serving undeserving clienteles. For example, as discussed below, conservatives in the 1930s and early 1940s argued that Social Security was not an actuarially sound system and that it was doomed to collapse under its own weight (Berkowtiz and DeWitt 2009). Another tactic is to prevent policies from being updated to reflect changing social circumstances, thereby rendering the policies less able to achieve their goals (Hacker 2004). An example is the US minimum wage, which conservatives have prevented from being raised to take inflation into account (Mettler 2016). Finally, conservatives can develop alternative policies to entrenched liberal programs, such as personal savings accounts as a substitute for Social Security. Such strategies of countermobilization may require long time horizons, as well as access to policy expertise and organizational capacity in think tanks and foundations (Teles 2007).

When have conservatives actually used these strategies, and under what political circumstances have they deployed them? Why, at times, have they chosen a strategy of policy acceptance rather than attempting to roll back new programs? How have conservative responses to the US welfare state changed over time? The following sections examine the postenactment responses of conservatives to the adoption of Social Security, Medicare, Medicaid, and the Affordable Care Act.

Social Security

The history of Social Security illustrates how conservatives' opposition strategies can shift over time, as well as how boundary issues can apparently be resolved only to be subsequently reopened. Social Security is today seen as America's most cherished and entrenched social program, but it was neither popular nor durable at the outset. Notably, unlike the ACA, Social Security passed with bipartisan support in Congress, which helped signal its legitimacy (Mayhew 2017). Yet Republican presidential candidate Alf Landon called for Social Security's repeal in the 1936 election, and conservatives in Congress continued to attack the program on financial, ideological, and constitutional grounds. The unwillingness of conservatives to embrace Social Security after its enactment is ironic, given that the anticipation of conservative opposition was one reason that Social Security was based on the contributory principle and that benefit levels were initially kept low (Berkowitz and DeWitt 2009). It underscores the extent to which many conservatives in the 1930s had deep-seated reservations about both the constitutionality and legitimacy of social insurance.

One early postenactment move of conservatives was to question the planned accumulation of a $47 billion reserve fund by 1980 to meet Social Security's future obligations without the need to tap general revenues. While payroll taxes began to show up in workers' paychecks in 1937, permanent benefit payments were not scheduled to begin until 1942. The prospect of the vast reserve buildup invited scorn from conservatives, who argued that the government would not be able to keep its hands off the money and would use it to finance, in the words of the Republican's 1936 party platform, “reckless and extravagant schemes” (quoted in Berkowitz and DeWittt 2009: 69). Moreover, the delay in benefit payments meant that senior citizens had no near-term material stakes in the program. A Democratic Congress in 1939 helped resolve the reserve controversy by moving up the starting date of Social Security benefits to 1942, increasing the generosity of retirement benefits, and extending coverage to a variety of groups (Derthick 1979; Patashnik 2000). The move away from reserve financing was also prompted by a desire to meet the threat of Townsendism and respond to criticisms of Keynesian experts, who argued that saving money would not boost the economy (Tynes 1996).

During the 1940s Social Security remained a vulnerable program and was perceived to be losing a popularity and legitimacy “race” with means-tested old age assistance, which had strong policy feedback effects since it started paying benefits immediately (Derthick 1979). Only in 1950, when a Democratic Congress liberalized benefits, did Social Security begin to gain solid ground (Patashnik and Zelizer 2013).

Some conservatives hoped that the election of Republican Dwight Eisenhower as president would give them the opportunity to recast the program. In 1953, the US Chamber of Commerce issued a proposal that would have combined state welfare programs for the elderly and Social Security into a single program. Coverage would be extended to all the aged immediately, whether or not they had paid payroll taxes. (The $18 billion balance in the Social Security trust fund would have been used to finance the transition.) The plan had obvious political appeal because it promised to widen coverage without increasing payroll tax rates (Patashnik 2000). Conservatives such as Representative Carl T. Curtis (R-NE) liked the proposal because it would expose the “myth” that Social Security was an “insurance” program in which workers paid for their own benefits. The proposal would highlight the fact that current workers were actually paying for the benefits of current retirees. Many conservatives believed that public awareness of how Social Security actually worked and who was bearing the costs would lessen the pressures for expansion (Derthick 1979). However, President Eisenhower, a domestic policy moderate, rejected the chamber's proposal and then embraced a major Social Security benefit expansion in 1954.

By the mid-1950s, conservative officeholders had largely resigned themselves to contributory financing, which put an upward limit on benefit growth but also reinforced perceptions of earned rights and put pressure on the government to make good on pension promises (Altman and Marmor 2009). Conservatives pursued a strategy of “piecemeal resistance to piecemeal advances” in which they tried to hold the line on benefit expansions (Derthick 1979: 132). Their strategy was unsuccessful. Between the start of the program and 1983, Congress made ninety-two changes in monthly benefit calculations (Derthick 1990; Mayhew 2017). Virtually all of these changes made Social Security more generous for retirees and provided many credit-claiming opportunities for reelection-seeking lawmakers of both parties. While some conservatives like Representative Curtis tried to galvanize fellow conservatives by arguing that the trust fund rested on accounting fictions, that the public would receive far more back in benefits than they had paid in, and that the program would eventually collapse, the benefit hikes were certified by Ways and Means Committee Chairman Wilbur Mills (D-AR) and the program's respected actuary, Robert J. Myers, as being fiscally sound (Zelizer 1999). Social Security's maintenance and growth were thus woven into Congress's routines, as well as into the fabric of American society. As Campbell (2003: 2) has shown, Social Security's growth in the 1950s, 1960s, and 1970s generated self-reinforcing policy feedback effects, transforming the “once-marginalized senior population” into a highly engaged constituency “with politically relevant resources like income and time.”

While Social Security's expansion and rising popularity created the impression that conservatives' opposition to the welfare state had been vanquished, in reality it was only sleeping (Altman and Marmor 2009). In 1981, the Reagan administration floated a proposal (announced by Secretary of Health and Human Services Richard Schweiker rather than the White House because of its political sensitivity) for $45 billion in Social Security cuts, including an immediate 25 percent reduction in benefits for those choosing early retirement. The unrealistic proposal unsurprisingly created a popular outcry, and the Senate voted 96 to 0 to oppose it (Pierson 1994: 66).

Given the positive feedbacks generated by Social Security's postwar growth, the best conservatives could do during this period was to use trust-fund financing crises as limited opportunities for retrenchment (Pierson 1994; Patashnik 2000). By the early 1980s, the Social Security system was running annual deficits, and the Social Security fund was projected to be exhausted by 1982. In 1983, Congress passed bipartisan legislation, based on the recommendations of a blue ribbon commission, to stabilize the system's finances. The 1983 Social Security “bailout” package contained cuts in long-term benefits as well as revenue increases, but no structural reforms to the program.

For conservatives, the whole series of Social Security events during 1981–83 was a bitter disappointment. It reinforced conservatives' belief that it was politically pointless to try to cut Social Security benefits in the near term and that a better long-term strategy was to alter “the conditions that would face subsequent generation of reformers” by developing proposals for Social Security's privatization (Teles and Derthick 2009: 267). During the 1970s, conservative think tanks like the Cato Institute began building intellectual capacity to craft market alternatives to Social Security in the hope that a window of opportunity would open once Republicans secured electoral gains. By the 1990s, the Democrats' alleged “permanent” congressional majority had collapsed, allowing the privatization idea to be taken seriously in the Washington political community—something that was impossible to imagine a generation earlier when Social Security was reputed to be the “third rail” of American politics that no politician dare touch (Weaver 2012). George W. Bush made the creation of “personal accounts” an issue in the 2000 presidential campaign. In Bush's 2004 State of the Union address, he argued that “younger workers should have the opportunity to build a nest egg by saving part of their Social Security taxes in a personal retirement account.” Bush's privatization proposal reopened the key boundary question of whether there should be Social Security, and what responsibility the public and private spheres have to protect the elderly.

However, Bush's Social Security proposal never gained traction despite the GOP holding majorities in the House and Senate. Democrats refused to get on board, and soon even congressional Republicans conceded that the proposal was dead. Voters never embraced Bush's privatization ideas. “The more the President talked about Social Security, the more support for his plan declined” (Galston 2007: 2). The Bush administration had hoped to leverage support for Social Security privatization from business coalitions and conservative groups like the Club for Growth. “But business support for Social Security individual accounts proved less than solid, in part because of strong actions by organized labor” (Weaver 2012: 138). Meanwhile, powerful interest groups like AARP and AFL-CIO adamantly opposed the idea and spent millions to defeat it. Finally, policy feedback effects reinforced the existing Social Security system's durability (Beland and Waddan 2012). Bush's plan involved shifting from a pay-as-you-go to an advance funded system (since personal accounts were to be funded out of earnings, rather than taxes). The plan promised to honor the pension commitments to retirees and workers near retirement age. To do otherwise would be to ensure that the plan did not even get a hearing. As a result, the plan faced a “double payment” problem: workers would need to continue financing retirees while also saving for their own retirements. The transition costs of the plan were massive, on the order of $1 trillion (Galston 2007). Bush never found the money to cover these costs, having prioritized tax cuts. The vanishing of federal budget surpluses following these tax cuts and the 9/11 terrorist attack, as well as stock market declines and the collapse of Enron Corporation and its employees' retirement accounts, made Social Security privatization an impossible task for the Bush administration (Weaver 2012). Given these sobering dynamics, it is not surprising that “most Congressional Republicans did not share the president's enthusiasm for touching the third rail” (Weaver 2012: 141).

In sum, conservatives' countermobilization strategy found support among party leaders and policy intellectuals and contributed to an erosion of Americans' confidence about the future of the program. But while conservative attacks on Social Security as a “Ponzi scheme” or “bad investment” have been corrosive, they nonetheless could not wear down the positive policy feedback and settled public expectations of Social Security. Even with unified Republican government, conservatives failed to privatize Social Security and uproot the program. In a 2014 Pew survey, 67 percent of Americans (and 61 percent of millennials) said Social Security benefits should not be reduced (Desliver 2015).

Medicare

Medicare was created largely in Social Security's image. By emulating Social Security's social insurance arrangements—including universal coverage of the elderly for hospital care regardless of income and payroll tax financing that established eligibility as an earned right—Medicare's architects hoped to ensure its sustained success (Marmor 1973; Oberlander 2003). The debate over Medicare's enactment was nonetheless highly controversial. The American Medical Association, which feared government intrusion into physicians' professional autonomy and the slippery slope of “socialized medicine,” fiercely resisted Medicare. Federal health insurance through Social Security also was anathema for conservatives. Most congressional Republicans, many Southern Democrats, and business groups opposed Medicare. A shifting political environment eventually rendered such opposition futile. The Democratic electoral landslide of 1964 made Medicare's passage the following year inevitable (Marmor 1973). The large majorities that ultimately enacted Medicare—313 to 105 in the House and 68 to 21 in the Senate—obscured the extent to which conservatives opposed the program until its passage was a fait accompli (Blumenthal and Morone 2009). Still, the fact that Medicare received support from a slim majority of House Republicans and almost half of GOP Senators gave Medicare a bipartisan imprimatur.

What is most striking about Medicare's immediate postenactment experience is what did not happen: there was no serious conservative effort to repeal Medicare or challenge its constitutionality. The Medicare debate effectively ended with the program's passage. The program was up and running within a year—a remarkably fast and smooth rollout that the ACA, as we note below, did not match (Patashnik and Zelizer 2013). Medicare quickly embedded itself as one of the nation's most popular social programs. Medicare's postenactment success reflected the fact that Medicare delivered highly visible and valuable benefits to a population (the elderly) that could command public sympathy, as well as the program's solicitous administrative decisions and favorable payment policies that were a financial boon for physicians and hospitals (Feder 1977; Marmor 1973; Oberlander 2003).

Medicare was too popular and entrenched for conservatives to attack directly. Instead, fiscal conservatives focused on cost containment. Only four years after its passage, Senator Russell Long (D-LA), chair of the Senate Finance Committee, branded Medicare a “runaway program” because of much higher than expected costs (Oberlander 2003). By 1970, actuaries were projecting that the program's hospitalization insurance trust fund would be insolvent in 1973, the first in a series of trust fund crises that would periodically dominate Medicare politics (Oberlander 2003; Patashnik 2000; Pierson 1994). During the program's first three decades, Republicans worked with Democrats during the Reagan and Bush administrations to adopt a series of reforms that aimed to contain program spending (Mayes and Berenson 2006; Oberlander 2003; Smith 1992). Supporting expansion of government regulatory powers and erstwhile “price controls” to limit rising Medicare expenditures and reduce the federal budget deficit was a mainstay conservative position during the 1980s and 1990s. Medicare policy reflected efforts to rationalize the program rather than dismantle it (Brown 1983).

However, the relative stability of Medicare did not mean that conservatives embraced liberals' programmatic vision. Conservative alternatives to Medicare date back to its enactment. In 1965, Republicans favored a proposal to subsidize the aged to purchase private health insurance as an alternative to government-operated insurance. In the 1980s, some policy analysts, inspired by Alain Enthoven's managed competition model, proposed Medicare vouchers. Legislation to give Medicare beneficiaries vouchers that would enable them to purchase private coverage and receive rebates if they chose less expensive plans was considered during the Reagan administration (including a 1982 House bill sponsored by Democrat Richard Gephardt and Republican David Stockman) (Fuchs and Potetz 2011). But proposals to radically restructure or convert the program into a voucher system did not gain much traction during Medicare's first three decades of operations, largely because Republicans never gained control over both the House and Senate during this period.

After the GOP won congressional majorities in the 1994 elections, conservatives saw an opening to pursue more ambitious policies. Under Speaker of the House Newt Gingrich, Republicans pressed to end Medicare's budgetary entitlement status while capping program spending and converting Medicare into a competitive private market. Republicans cited concerns about Medicare's financial sustainability, arguing that they were saving the program before it went bankrupt (White 2003). Republicans passed legislation to transform Medicare in 1995, but President Bill Clinton vetoed the GOP bill.

Since that time, however, conservatives have increasingly pushed for proposals to radically alter Medicare in the name of entitlement reform and securing the program's long-term solvency. In a landmark 2011 vote that underscored the profound changes in Medicare politics, House Republicans passed a plan developed by then Budget Committee Chair Paul Ryan that would have eliminated the traditional Medicare program entirely and replaced it with a voucher system, leaving beneficiaries with a choice of only private plans. Congressional Budget Office projections showed that the Ryan plan, which also proposed raising the Medicare eligibility age, would have badly eroded Medicare's insurance protection for older Americans and persons with disabilities. The proposal drew intense opposition from Democrats and fierce resistance from senior advocates and AARP and proved unpopular with both Medicare beneficiaries and the broader public. That reaction reflected the political challenges inherent in Medicare vouchers. Conservatives favor them as an instrument to contain federal Medicare spending, but to generate substantial budgetary savings a voucher system has to impose large costs and benefit cuts on program enrollees, a controversial departure from the status quo. The Ryan plan did not pass the Senate, and although Ryan and other conservatives continue to promote Medicare premium support, they have not succeeded to date in securing its enactment (Oberlander 2014b).

Despite the political obstacles to voucherizing Medicare, conservatives have had more success in altering its programmatic character by pushing Medicare toward the market (a change fueled as well by developments outside of Medicare). The Bush administration and a Republican majority Congress enacted a Medicare prescription drug benefit (Part D) as part of the 2003 Medicare Modernization Act (MMA). Benefit expansion is not a conservative aspiration, but the Bush administration saw Medicare prescription drug coverage as vital to the GOP's short- and long-term political prospects (Jaenicke and Waddan 2006; Morgan and Campbell 2011; Oberlander 2012a; Oliver, Lee, and Lipton 2004). (Actually, the two largest benefit expansions in Medicare's first four decades, including the MMA and the 1988 Medicare Catastrophic Coverage Act, came under Republican presidents, demonstrating conservatives' political quandaries in managing welfare state programs and politics.) Republicans, though, did succeed in enacting the 2003 drug benefit on conservative terms; it was offered not as part of the traditional government-run Medicare program but exclusively through private insurers. Medicare Part D marked an important beachhead for privatization (Beland and Waddan 2012; Morgan and Campbell 2011). It also represented an advancement of managed competition, an approach to health reform that has long appealed to many conservatives because it relies on private insurers as an alternative to government-run programs while emphasizing the virtues of markets and consumer choice (Enthoven 1993).

The MMA also increased payments to private plans that contract with Medicare to provide medical care to program enrollees through the Medicare Advantage program. Over time a combination of market trends (the rise of managed care in private insurance) and policy measures (including the Bush administration's payment increases to insurers) produced a major expansion of Medicare's private coverage component (Kelly 2016). Today, nearly one-third of Medicare beneficiaries are enrolled in a private plan. The expansion of private insurance within Medicare has remade its politics, giving insurers a stronger influence over program policy, as well a stake in its further privatization, and Democrats a stake in maintaining their constituents' access to private plans (Kelly 2016). Medicare has not been formally voucherized, but it has nonetheless become a hybrid of public and private insurance, with a growing role for private plans and a diminished place for the traditional, federally run Medicare program (Oberlander 2014b). In sum, while conservatives did not succeed and in fact did not try to eliminate Medicare after its enactment, they have sought to constrain and reshape it. Republicans increasingly have pushed plans that would radically transform the program, and Medicare has changed in ways that reflect conservative principles.

Medicaid

Congress enacted Medicaid as part of the same 1965 legislation that created Medicare, yet Medicaid had different origins than Medicare and a contrasting programmatic structure and philosophy. Put simply, conservatives preferred the programmatic design and philosophy of Medicaid to that of Medicare. Medicare was social insurance; Medicaid was welfare medicine (Brown and Sparer 2003). Medicaid was means tested, with eligibility restricted to certain categories of low-income Americans. It relied on general revenue funding rather than earmarked payroll taxes (which financed Medicare's hospitalization insurance). States would run their own Medicaid programs under federal rules, in contrast to Medicare, which Washington administered. While Medicare's roots were in Social Security, Medicaid grew out of an alternative to Medicare proposed by the American Medical Association and an already established means-tested medical care program for the elderly (Kerr-Mills) that conservatives had backed to try to stop Medicare from becoming law (Grogan and Patashnik 2003). Advocates and opponents alike saw Medicare as a potential cornerstone for national health insurance, whereas Wilbur Mills envisioned Medicaid's enactment as “build[ing] a fence around Medicare” so it couldn't expand (Marmor 1973: 69).

By 1970 all but two states had adopted Medicaid programs. There was no sustained, coordinated effort to reject Medicaid by conservative state leaders or to repeal it in Congress. Yet in its early postenactment period, Medicaid, like Medicare, encountered fiscal issues that created political openings for conservative critics. “A handful of liberal states—especially New York and California—would move rapidly to establish capacious Medicaid programs” (Thompson 2015: 193). Federal lawmakers recoiled at New York state's expansionary interpretation of Medicaid eligibility rules for medically needy persons. Congress responded by adopting legislation in 1967 to restrict Medicaid eligibility (Grogan and Patashnik 2003; Sparer 1996). The new rules reduced “the number of potential Medicaid recipients . . . by 750,000 in 1968 and 900,000 persons in 1969” (Grogan and Patashnik 2003: 827). They also “firmly established Medicaid as ‘welfare medicine,’ linking eligibility for the program to that for Aid to Families with Dependent Children (AFDC)” (Thompson 2015: 193).

Despite the efforts of fiscal conservatives to contain Medicaid, its expenditures grew. While Congress did impose eligibility limits, other early legislative efforts to restrain spending, including capping federal payments to states and reducing funding for long-term care, did not pass. Those efforts failed partly because of “intense lobbying by the nation's governors” (Rose 2013: 51). Medicaid brought in substantial money to states, giving them a powerful incentive to oppose federal retrenchment. As Rose (2013: 51) explains, “in a striking case of policy feedback, state leaders emerged as a supportive constituency for the new program, immediately constraining federal lawmakers' ability to reverse course.”

Despite the cost concerns, the Nixon administration and Congress actually expanded the program's reach in 1972, with the newly established Supplemental Security Income program, which created more generous eligibility standards for aged, blind, and disabled persons receiving cash assistance (Sparer 1996; Thompson 2015). President Nixon did propose eliminating Medicaid coverage for AFDC recipients as part of his 1971 national health insurance proposal (a new Family Health Insurance Plan would cover the unemployed and low-income persons). However, the Nixon health care plan went nowhere, and Medicaid remained in place. Like Medicare, in Medicaid's early years the focus of conservatives, as well as liberals, was on rationalizing the program and constraining its growing costs, not dismantling it.

Conservatives gained an opening to pursue more radical Medicaid retrenchment with the election of Ronald Reagan to the presidency in 1980. The Reagan administration sought to downsize the welfare state, contain spending on federal social programs, and devolve more responsibility to the states. The administration “aggressively pursued several initiatives that would vitiate Medicaid as an open-ended entitlement to the states” (Thompson 2015: 194). These proposals included capping federal Medicaid payments to states, block granting the program while granting states more flexibility, and assuming federal control over Medicaid (with major benefit and eligibility cuts) in exchange for the states taking over AFDC and food stamps (Rose 2013: 78; Smith and Moore 2008). None of these measures to curtail the Medicaid entitlement passed Congress, though the Reagan administration did manage to secure legislation reducing federal payments to states for three years. Instead of being dismantled, “Medicaid emerged from the Reagan years virtually unscathed, largely due to state leaders' entrenched interest in preserving the status quo” (Rose 2013: 102).

Ironically, Medicaid began a remarkable expansionary trajectory during the Reagan years. During 1984–90, Congress, driven by California Democrat Henry Waxman's efforts and leveraging of the budget reconciliation process, repeatedly expanded Medicaid eligibility for pregnant women and children (Brown and Sparer 2003; Smith and Moore 2008). The Medicaid expansions attracted support from governors who welcomed more federal funding, especially southern governors who sought to address high infant mortality rates (Rose 2013). Expanding Medicaid coverage for women and children also appealed to some antiabortion conservatives in Congress, such as Republican Henry Hyde (R-IL), who saw the measures as “prolife.” Enlarging Medicaid was a more politically palatable outcome for conservatives than Medicare expansion, since it entailed extending a means-tested program operated by the states, even though it helped break Medicaid's historical links to welfare.

After gaining congressional majorities in the 1994 elections, though, Republicans pursued a more ambitious Medicaid agenda, reviving Reagan-era proposals to restructure the program with support from Republican governors. Congress passed legislation to block grant Medicaid in 1995, and when President Clinton vetoed it, Republicans shut down the federal government to try and compel him to reconsider (Thompson 2012). Clinton in fact initially agreed to a per capita cap on Medicaid, in effect “accepting the Republican argument that the federal government's financial commitment to Medicaid should not be completely open-ended” (Thompson 2012: 41). However, Republicans saw Clinton's concession as inadequate. Meanwhile, public opinion, shaped in part by the president's efforts to emphasize the negative impact that block granting would have on older Americans who benefited from Medicaid, turned against the GOP plan. Conservatives' efforts to block grant Medicaid failed, and “Republican leaders came away with a new sense of the political risks of frontal attacks on the program” (Thompson 2012: 46). While in 2003 the Bush administration proposed an optional capped Medicaid grant and in 2011 House Republicans passed Paul Ryan's proposal to block grant and make substantial cuts in Medicaid, neither plan became law.

In sum, conservatives initially supported the Medicaid model—“welfare medicine”—as an alternative to Medicare to cover the elderly (Sparer 1996; Stevens and Stevens 1974). After being enacted as a companion program to Medicare that would cover select categories of the nonelderly poor, Medicaid experienced a surprising trajectory that defied expectations for a “poor program” (Brown and Sparer 2003). The attractions of fiscal federalism, with Washington and the states sharing the bill, fueled the program's growth, created influential political constituencies for Medicaid among governors as well as the health care industry, and helped ensure its political durability. However, conservatives' support for and accommodation of Medicaid did not last. Since 1980, opposition to Medicaid has grown on the right. Republicans have periodically sought to end Medicaid's status as a budgetary entitlement, sharply curtail federal spending on the program, and shift more responsibility to the states. What was once a conservative model has become a target of retrenchment and entitlement reform.

The Affordable Care Act

Republicans intensely opposed the ACA's enactment. Not a single Republican in Congress voted for the law in 2010, making it a shaky candidate for postenactment embedding (Mayhew 2017). Nonetheless, ACA supporters had reasons to believe that it could become an entrenched feature of the welfare state. After all, the debate over Medicare had been divisive, but controversy faded following its enactment. Moreover, the ACA was, in crucial respects, conservative in its design (Oberlander 2014a). It was modeled on the 2006 Massachusetts reforms supported by Republican Governor Mitt Romney and virtually all that state's GOP lawmakers. The ACA built on private, employer-based health insurance rather than creating a government-run, single-payer system. The law did not create, as many liberals had wanted, a new government-sponsored insurance program or “public option” for the uninsured. It incorporated ideas once advocated by conservatives, including the individual mandate, tax credits, and insurance purchasing pools, while relying on private insurer competition, consumer choice, and high-deductible insurance.

Yet conservative opposition to the ACA did not dissipate after 2010. The ACA's postenactment experience has been characterized by constant conflict, widespread challenges to its implementation, and serious threats to its existence (Oberlander 2016). Conservatives have used myriad legal, legislative, and fiscal strategies to undercut the ACA's entrenchment. Republican-led states joined a suit against the law that challenged the constitutionality of the individual mandate that required most Americans to obtain insurance coverage or pay a penalty to the federal government. In 2012, the Supreme Court narrowly upheld the mandate as a tax, but surprisingly ruled that the ACA's Medicaid expansion was unconstitutional because it unduly coerced states.

That ruling effectively made Medicaid expansion optional for the states, giving Republicans an opportunity to undercut a central pillar of the ACA's insurance expansion. Despite the lure of federal funding (Washington would initially pay 100 percent of the costs, with the federal share eventually declining to a still generous 90 percent), the political influence of hospital lobbies that wanted more insured patients, the support in many states of business associations, and the potentially sizable benefits to state economies and budgets, eighteen states had declined to expand Medicaid eligibility as of 2017. The politics of Medicaid resistance has been highly partisan: sixteen of the rejectionist states had Republican governors, with the other two having Democratic governors and Republican-majority legislators, though ten GOP-governed states had expanded Medicaid (Rose 2015). Medicaid rejectionism also has reflected the growing influence of right-wing networks that are active in state politics, such as the Koch brothers–funded Americans for Prosperity and the American Legislative Executive Council (Hertel-Fernandez, Skocpol, and Lynch 2016). In some GOP-led states, the strong opposition of such conservative networks to Medicaid expansion served as an effective counter to support for liberalizing the program from Republican governors and groups such as hospital associations and chambers of commerce (Hertel-Fernandez, Skocpol, and Lynch 2016).

Conservative opposition to the ACA emerged on another important front with the states. Health insurance exchanges, the purchasing pools where the uninsured can shop for coverage, became a major flashpoint in ACA implementation (Beland and Waddan 2016; Jones, Bradley, and Oberlander 2013). The controversy came despite the fact that Republicans had previously proposed such purchasing pools in their own reform plans. Virtually all Republican-governed states refused to create exchanges, leaving the federal government responsible for their establishment and operation. Many of these states have played no role in and devoted no resources to promoting ACA enrollment, and some have adopted policies that make signing up for coverage more difficult, such as imposing stringent requirements on the navigators who assist in the enrollment process (Jones 2017).

State opposition to Medicaid expansion and insurance exchanges highlighted a key ACA vulnerability (Starr 2011): it relied on states to implement core provisions at a time both of exceptional partisan polarization and of rising Republican electoral strength at the state level. Resistance to the ACA, especially in its early days, did not simply come from GOP governors and lawmakers. In some cases, such as insurance exchanges and Medicaid expansion, conservative groups, including the American Legislative Executive Council, pressed establishment Republicans to boycott the ACA (Jones, Bradley, and Oberlander 2013).

At the federal level, congressional Republicans voted to repeal the ACA over sixty times during 2010–16. As long as Barack Obama remained in the White House, those votes were symbolic since repeal had no chance of becoming law. But the GOP did enact anti-ACA legislation that drew far less attention yet had a significant impact on its implementation. In 2014, Republican Senator Marco Rubio inserted a little-noticed provision into a budget bill that prevented the Obama administration from fully reimbursing insurers for their financial losses on ACA plans. The administration consequently could pay insurers only about 12 percent of what they were owed by the federal government under such risk-corridor payments (which Republicans denounced as insurer “bailouts”). That exacerbated instability in the insurance exchanges as the lack of full payments contributed to insurers increasing premiums. The Republican Congress's refusal to renew risk corridor and reinsurance payments was a factor in many insurers raising premiums substantially during 2016–17.

Republican resistance to the ACA in Congress during 2010–16 was also notable for what didn't happen: any bipartisan efforts to address the law's problems and strengthen its operation. Such fixes occurred periodically after Medicare's enactment, but in the polarized political environment that engulfed the ACA, the politics of repeal rather than rationalization has shaped its implementation. Rather than trying to fix the ACA, Republicans have highlighted and exaggerated its problems, both real and imagined, to delegitimize the law and create the conditions for its repeal. Some of those problems were created or worsened by GOP opposition that produced a self-fulfilling prophecy of disappointing performance, which Republicans than used as grounds to attack the ACA (Oberlander 2016).

Sustained conservative resistance to the ACA raises two puzzles: why has conservative opposition to the ACA been so deep and persistent, and why has the ACA been politically vulnerable? Republicans' sustained resistance to the ACA makes sense given the party's rightward drift and ideological commitments. Whatever its conservative design features, the ACA nonetheless entails a vast expansion in the role of activist government and shifts the boundary between public and private responsibilities. It also moves the United States toward establishing a right to health care. Conservatives have long recognized that such a right would be hard for the government to abridge once embedded in public expectations.

Moreover, as data analyzed by Aaron and Burtless (2014) show, the ACA is highly redistributive (see fig. 2). Indeed, the ACA is arguably “the federal government's biggest attack on economic inequality since inequality began rising more than three decades ago” (Leonhardt 2010: A1). The ACA funds insurance coverage for low-income Americans largely through higher taxes on wealthier Americans. Given the GOP's rightward shift, increasing hostility to progressive taxation and other redistributive policies, and electoral incentives, it is ultimately not surprising that conservatives have used all available weapons to oppose and weaken the ACA.

Following the 2016 election, which saw Donald Trump winning the White House and Republicans retaining control of Congress, the GOP at last appeared to have secured the political conditions necessary to make good on its pledge to repeal the ACA. The president and Republican congressional leaders made repeal and replace a legislative priority during the administration's first year. While the House of Representatives did succeed in passing such a bill, Republicans initially could not get similar legislation through the Senate. Republicans failed largely because the GOP had a slim majority (52–48) in the Senate and majority leader Mitch McConnell could not keep a few Republican Senators (John McCain, Lisa Murkowski, and Susan Collins) from joining with all Democrats in opposition to repeal and replace legislation. Republicans' difficulties in dismantling the ACA also reflected conservatives' inability to fashion a credible alternative—the Congressional Budget Office forecasted that GOP bills would have increased the uninsured population by over 20 million and jeopardized access to affordable coverage for persons with preexisting conditions (Oberlander 2017). Republican health care plans illuminated the considerable costs of taking away the ACA's benefits without adopting an adequate replacement.

Moreover, the GOP repeal plans went beyond the ACA in proposing to cap federal funding for Medicaid, a radical change in the program's financing arrangements that helped produce a projected $800 billion cut in Medicaid funding over ten years. The prospect of a massive cut in Medicaid highlighted its vast scope—over 70 million Americans are enrolled in the program—and the crucial role that Medicaid plays in financing care for children, pregnant women, older Americans, persons in nursing homes, persons with HIV/AIDS, individuals with serious mental health issues and disabilities, and persons with substance use disorders, including opioid addiction (KFF 2017). Medicaid's scope also makes it vital to the health care industry, and many medical care providers, especially hospitals, stood to lose much revenue from the proposed cuts in program spending. The threat to Medicaid from GOP proposals, as well as to the ACA's policies to promote access to affordable insurance, ignited strong opposition to repeal and replace legislation from virtually all health care stakeholders, encompassing both industry and consumer groups. Republican plans also triggered a grassroots campaign to protect the ACA. The GOP health care legislation registered as the least popular major bill of the past three decades; in fact, the specter of Republicans pulling the plug on the ACA substantially increased the ACA's popular support during 2017 (Oberlander 2017).

Still, despite all of the barriers that normally would doom major legislation to defeat, the GOP majority in the House did pass a repeal and replace bill. If Republicans had just a few more seats in the Senate, there is strong possibility it would have followed suit. This was a near miss.

Frustrated by the GOP's inability to pass a repeal bill through Congress, President Trump began using executive administrative tools to unravel the ACA. The Trump administration eliminated almost all federally sponsored advertising promoting enrollment in the insurance Marketplaces, shortened the open enrollment period for ACA plans, and cut funds to groups that help people navigate their coverage choices. Additionally, the president issued an executive order to expand the availability of short-term insurance policies for individuals and association health plans for small businesses, both of which would permit sale of plans that are exempt from the ACA's insurance regulations and consumer protections, thereby potentially encouraging healthy persons to leave insurance pools. President Trump also ended payments to insurers for cost-sharing reductions that help pay for deductibles and copayments for persons with modest incomes. While the impact of these actions remains uncertain, the Trump administration's intent—to damage the ACA, especially its insurance marketplaces—is clear.

Not content with these executive plans to sabotage the ACA, in December 2017, with President Trump's encouragement, Senate and House Republicans passed legislation as part of a broader tax bill to eliminate the ACA's individual mandate penalty for not obtaining insurance. Canceling that penalty could further destabilize the individual insurance market and lead to more insurance pools with older, sicker populations and higher premiums. While most prior GOP plans had offered substitutes for the individual mandate to avoid such consequences, the plan enacted by Congress offered only repeal and no such replacement. Repeal of the mandate penalty represents Republicans' first major legislative victory in their war on Obamacare (Beland and Waddan 2016), though most of the law remains intact.

While the ACA is far more durable than many conservatives predicted it would be, key features of its policy design and implementation experience have frustrated its embedding (Patashnik and Zelizer 2013). The ACA offers important benefits to millions of Americans—including, for those who qualify, access to subsidized private coverage in the marketplaces, insurance regulation that prohibits discrimination against persons with preexisting conditions, and the ability to keep young adults on their parents' health plans. When those benefits were threatened following President Trump's election, many Americans realized they had a real stake in the program. However, the ACA provides different benefits to different groups of Americans at different times; it is less a single program than a Byzantine series of subsidies, regulations, and mandates (Oberlander 2012b). That has made it difficult for supporters to explain what it does. The ACA's major insurance benefits did not start until four years after the law's enactment, which delayed constituency building. Once the law took effect, problems with implementation, including the botched rollout of healthcare.gov, created self-undermining feedbacks that weakened its entrenchment (Oberlander and Weaver 2015).

Further, many middle-class persons continue to struggle with health care costs. The ACA offers comprehensive benefits to persons who are eligible for Medicaid expansion (and live in states that have expanded) and very low-income persons buying coverage through the law's insurance exchanges. But persons who are not in the very-low-income group receive more limited financial assistance to purchase insurance and often face high costs for premiums, deductibles, and copayments. Meanwhile, out-of-pocket costs continue to rise for Americans with employer-sponsored insurance, a trend predating the ACA that the law has not reversed. In addition, the ACA is not social insurance and thus lacks the contributory financing design that has helped generate perceptions of “earned rights” and moral deservedness. Finally, the ACA's primary beneficiaries—low-income Americans, including many childless adults—are not as politically influential or sympathetic a group as the elderly.

Taken together, these features help explain why the ACA has never come close to generating the exceptionally high levels of public support that Medicare or Social Security achieved. In key respects—a focus on low-income persons, state administration, means-tested benefits, the absence of payroll tax funding—the ACA has more in common politically with Medicaid than with Social Security or Medicare.

Conclusions

Conservatives in the United States have never accepted the legitimacy of a large, permanent welfare state, but their strategic responses to the enactment of new federal commitments in the key areas of pensions and health have varied both over time and across programs. Our account draws attention to three key factors that help explain why Social Security had a difficult infancy but then grew into a robust program, why Medicare was essentially born entrenched, why Medicaid has appeared to mature but then struggled, and why the ACA has not yet escaped its childhood troubles.

The first and most important factor is the evolving political identity of conservatism (Pierson and Skocpol 2007). Since the New Deal, conservatives have resisted the growth of the US welfare state, but their views have become more ideologically pure over time. In the 1950s and 1960s, many conservatives acquiesced to an expansion of safety net programs for “deserving” groups like the elderly and the poor. It was during this relatively tranquil period that Social Security matured and Medicare and Medicaid emerged as central pillars of the welfare state.

Such tranquility has long since disappeared. The recent emergence of the hard-right House Freedom Caucus in the aftermath of the ACA debate symbolizes the resurrection of libertarian and antistatist ideas and the GOP's rightward turn. As moderates within the Republican party lost power to conservatives over the past half century as a result of the civil rights movement, the growing agitation of party base voters, and the emergence of the “Koch” network connecting big money funders and issue advocates (Hacker and Pierson 2016; Skocpol and Hertel-Fernandez 2016), conservatives' political and policy goals, as well as their strategies, have become more radical. Linking “newly energized associations and networks to partisan politics,” an invigorated conservatism now pursues increasingly bold objectives, aiming to circumscribe and redirect big government (Pierson and Skocpol 2007: 4). Whatever the ACA's substantive merits, conservatives' strategic choices to oppose it are explicable given the incentives for radicalism created by the primary system, conservative media, and donor-funded organizations.

Second, conservatives' strategies of resistance and accommodation have been shaped by the institutional resources available to them, especially partisan control of government. Throughout most of the postwar era, Republicans were in the political minority in Congress. Even with the support of Southern Democrats, Republicans were rarely in a position of control and were forced to react to liberal Democratic proposals. Between 1955 and 1994, Republicans never held simultaneous majorities in the House and Senate. After 1994, though, Republican governance of Congress became commonplace. As conservatives have taken over the Republican Party and won elections giving them control both of Congress and of many state governments, they have gained more tools to pursue the dismantling of existing social programs.

Political polarization—which has sorted conservatives into the Republican Party and liberals into the Democratic Party—has given conservatives a much stronger electoral incentive to continue welfare state battles into the postenactment stage. It can be difficult for opponents of a policy to remain engaged in a battle over the long haul when members of the opposing coalition belong to different political parties. The broad coalition may face a significant collective action problem and may lack a clear audience for its lamentations. As Mayhew (2012: 263) writes, however, “A party (as opposed to a cross-party coalition) is an organization built exactly to generate messages and mobilize voters. A party that loses on a congressional issue, if it was unified in that confrontation, and stays angry, may have an incentive to keep that conflict going.” Polarization makes it harder to bring Democrats and Republicans together not only on final passage but also during the crucial implementation phase.

Third, patterns of conservative resistance and opposition to social programs are also shaped by the nature of policy feedback. Both the material benefits and costs (resource effects) and the symbolic messages sent by policy designs (interpretive effects) influence conservative attempts to roll back welfare state commitments (Pierson 1994). When social policies confer substantial economic benefits on recipients, and treat them with dignity, as in the case of Social Security and Medicare, constituency groups organize and develop the capacity to defend their benefits against threats (Campbell 2003). But when programs treat eligible citizens as morally suspect or underserving, as in the former AFDC program, recipients are less likely to participate in politics, rendering their programs more vulnerable to attack. Medicaid and the ACA are mixed cases in terms of policy feedback. While these programs do confer significant economic benefits on some citizens (as well as on key actors, e.g., hospitals and state governments), their targeted beneficiary groups lack clear social identities and organizational cohesion.

Conservative strategies of resistance and accommodation may also reflect political calculations about those beneficiary groups. Some groups, such as older Americans, may be seen as more popular, sympathetic, politically influential, and electorally important, while others, such as low-income, working-age adults, may be seen as less so, making it easier to target programs serving them for cuts or repeal (and harder to build feedback effects). Medicare and Social Security have more political insulation than does the ACA, whose benefits go largely to low-income adults.

The ACA has been caught up in a perfect storm. Its patchwork design has created only moderately robust feedback effects, and its embedding has occurred at a moment when conservatives have become radicalized and gained control of the levers of power in both Washington and many states. Moreover, the ACA's redistributive financing collided with Republicans' growing antitax ideology and commitment to lowering taxes on wealthy Americans. Opposition to the ACA represented, then, a culmination of shifting conservative strategies toward public social provision that may have long-run implications not only for the ACA's entrenchment but also for the durability of many programs. While Social Security, Medicare, Medicaid, and the ACA all survived the first year of the Trump administration, fiscal pressures building as a consequence of tax cuts, growing budget deficits, and Republicans' determination to roll back social programs may presage intense battles over the US welfare state in the years ahead.

Acknowledgments

We gratefully acknowledge the helpful comments on earlier drafts of the manuscript by Margaret Weir, a reviewer for the journal, and participants in the conference “Health Policy after the 2016 Elections,” sponsored by Brown University's Watson Institute for International and Public Affairs and the Journal of Health Politics, Policy and Law. We also thank David Bateman and John Lapinski for sharing data.

Note

1.

Measures to slow program costs and reduce benefit growth sometimes find support among liberals who believe that such adjustments will help strengthen programs' long-term fiscal fortunes and preserve benefits for the needy.

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